From Feb 2018... “Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain. Anke Samulowitz et al. Pain Research and Management, Volume 2018 |Article ID 6358624, Feb 2018. https://doi.org/10.1155/2018/6358624
Abstract
Background. Despite the large body of research on sex differences in pain, there is a lack of knowledge about the influence of gender in the patient-provider encounter. The purpose of this study was to review literature on gendered norms about men and women with pain and gender bias in the treatment of pain. The second aim was to analyze the results guided by the theoretical concepts of hegemonic masculinity and andronormativity.
Methods. A literature search of databases was conducted. A total of 77 articles met the inclusion criteria. The included articles were analyzed qualitatively, with an integrative approach.
Results. The included studies demonstrated a variety of gendered norms about men’s and women’s experience and expression of pain, their identity, lifestyle, and coping style. Gender bias in pain treatment was identified, as part of the patient-provider encounter and the professional’s treatment decisions. It was discussed how gendered norms are consolidated by hegemonic masculinity and andronormativity.
Conclusions. Awareness about gendered norms is important, both in research and clinical practice, in order to counteract gender bias in health care and to support health-care professionals in providing more equitable care that is more capable to meet the need of all patients, men and women.
5. Discussion
The purpose of this study was to review and condense literature on gendered norms about men and women with pain, gendered norms about how men and women with pain cope with their daily life, and gender bias in the treatment of pain. In the following, main findings are discussed and analyzed with theories related to the concepts andronormativity and hegemonic masculinity.
Among the main findings in this review was a distinct pattern of gendered norms described in pain literature, in line with hegemonic masculinity, that distinguished men’s and women’s perceptions, expressions, and coping with chronic pain. For instance, men were presented as being stoic, in control, and avoiding seeking health care [45, 46]. Women, on the other hand were presented as being more sensitive to pain and more willing to show and to report pain [62, 63], compared to men. These overall findings confirm a pattern of separation between men and women, not embedded in biological differences but gendered norms. The dichotomy between men and women has been described as a way to establish and maintain the gender order, allowing men’s dominance over women [33]. That women were described in comparison to men can also be seen as a proof for andronormativity in health care, stressing that men, and health problems more often present in men, tend to be considered as the norm, while women (and other social groups outside the norm) are seen as irregularities. Since men are the norm and perceived as being “normal,” women are compared to them. Although women have more pain than men [3, 7] and dominate most chronic pain diagnoses [3, 7], they are described in comparison to men, as being deviant from the norm, even when they are in majority.
Another main finding was the pattern of andronormativity in relation to certain pain diagnoses. There are conditions where pain is the only reported symptom. Those conditions are highly dominated by women and have been described as difficult to fit in to the traditional bioscientific medical system [69, 70]. They have low status in the medical hierarchy of diagnoses [35], and women with those diagnoses are often questioned as patients [69, 83]. The concept of andronormativity implies that men and masculinity dominate health care to such an extent that women and femininity become invisible. Our results showed that symptoms in women-dominated conditions that do not fit the masculine norm actually seem to be invisible. The definitions of these conditions in the reviewed studies have focused on the absence of medically provable signs, for example, “pain in the absence of diagnostic evidence” or “pain without organic pathology.” Accordingly, those conditions were not defined in their own terms but in terms of what they lack—in relation to the predominant medical norm. Interestingly, even women with those “medically unexplained” conditions have been treated as if their illness does not exist. Our results showed that those women have been described as “malingerers” or as “if the pain is all in her head” [49, 71]. An interesting finding worthy of future elaborations is that those pain conditions, which are predominantly suffered by women, are underexplored, and portrayed as a challenge for medicine [47, 70]. It would also be interesting to further investigate if the key for change lies in the dichotomous construction of gender, which can lead to different diagnoses given to men and women, despite equal needs or in the masculine stamp of bioscientific health care, which can lead to different approaches to high- and low-status diagnoses.
Another major finding is that women’s pain in the reviewed studies was psychologized [13, 72]. According to hegemonic masculinity, psychological strain is feminine coded and at the same time down-valued in comparison to somatic conditions [32]. Consequently, when their pain condition is psychologized by health-care providers, women can feel that their pain is down-valued or dismissed, which in turn can cause stress [82]. Stress cues can, in turn, lead health-care providers to take patients’ pain less serious [82], thus leading to a vicious circle. As long as stress and psychological strain are feminine coded, and a hierarchy between somatic and psychological findings exists in health care, there is a risk that not only the dichotomy between men’s and women’s pain, but also between somatic and psychological conditions is further consolidated.
Even men with chronic pain have to deal with hegemonic masculinity in health care. Physical strength is idealized in hegemonic masculinity, in opposition to weakness [33]. Chronic pain per se is a threat to idealized masculinities as pain generally goes along with loss of muscle strength. Our results indeed showed that physical strength was central for men’s gender identity, whereas weakness threatened it [54, 55], and that men with chronic pain risked to be perceived as more feminine than the typical man [50]. Imbedded in hegemonic masculinity is a competition for dominance among men, and the threat of losing masculinity is a threat of losing power [33]. Men in the reviewed studies showed different strategies, like denial and rejection, to deal with what could be described as a threat of losing masculinity ideals. An example is ignoring or questioning the diagnosis, or not following clinicians’ advice [48, 54]. Another interesting finding was that men according to the reviewed studies explained their pain with factors from outside, beyond their control [46, 57]. This may be a way for men to express that pain is not a part of them and their identity and could be understood as the attempt to keep the position as a masculine man by separating the feminine coded pain from the masculine man.
A recurrent finding in the studies reviewed was women’s struggle to try to handle pain and multiple demands from their surroundings simultaneously [75, 76]. Traditionally, as part of the gender order, women are responsible for their home and family and to take care of themselves. However, our results showed that an overload of responsibility for family, work, household, their pain, and their wellbeing seemed to be an obstacle for recovery for women with pain [49, 87]. Our results also showed that health-care providers considered it important that women learn to say “no” to demands from others [75]. Even if this may be thought as an attempt to lower women’s overload of responsibility, it can actually increase women’s responsibility [75]. This could be explained by hegemonic masculinity, where the subordinate part is expected to conform to the prevailing norm, making women responsible to solve their issue and also being responsible for the outcome. The consequences of hegemonic masculinity can increase the burden on women with chronic pain, as the reviewed studies showed.
In summary, our results confirmed a paradox, highlighted by Hoffmann and Tarzian [13]; compared to men, women have more pain, and it is more accepted for women to show pain, and more women are diagnosed with chronic pain syndromes. Yet, paradoxically, women’s pain reports are taken less seriously [13, 71, 78], their pain is discounted as being psychic or nonexistent [69, 70, 72], and their medication is less adequate than treatment given to men [2, 96]. This has been described as a paradox [13] but can be explained as an expression for hegemonic masculinity and andronormativity in health care.
5.1. The Relation between Gendered Norms and Gender Bias
Several researchers [2, 3] have emphasized the risk of gender bias in the treatment of pain; however, studies that demonstrated objectively measurable gender bias in medical treatment were less extensive and less consistent. Subjectivity in the assessment of pain makes pain experiences and pain treatment sensitive to gender norms [2, 12]. In addition, it is also reasonable to conclude that the subjectivity makes it difficult to prove malpractice related to gender. Nevertheless, when we searched for gender bias in pain, we found studies that showed that women received less adequate pain medication and more antidepressants compared to men [86, 98]. In addition, a pattern of parallels between gendered norms and gender bias could be demonstrated in the results. For example, gendered norms were expressed through presumptions such as “women are more emotional than men” [49, 71]. The psychologizing of women’s pain [13, 70] reflects this norm, and that antidepressants are more often described to women compared to men [22, 97] could be a consequence of it.
5.2. Consequences of Gendered Norms in Health Care
The notion of men and women as separate and different in manners and needs is problematic [106], as it can consolidate gendered norms, which in turn can lead to individual needs being overlooked [106]. Health is constituted within a wide range of gender-related experiences [106]. The patient-provider relation is one domain for constitution, reinforcement, or challenge of gendered norms, where andronormativity and hegemonic masculinity can cause health-care providers to treat men and women based on gendered norms rather than individual needs. For instance, gender norms like “men need to be physically strong” [43, 54, 58] can lead to the presumption that active leisure time is more important for men than for women, which in turn can lead health-care professionals to recommend men, but not women, to continue with sport activities despite their pain [54, 85]. Or, as another example, if women are seen as the primary care giver and responsible for family and household [49, 58, 71, 80], this can lead professionals to recommend women, but not men, to prioritize family above work and leisure time [22, 58]. Increased awareness of gendered norms and potential gender bias is a prerequisite to counter gender bias in health care [20]. There is a power imbalance between men and women, and many (though not all) gender biases are to women’s disadvantage [20]. However, both men and women are restricted by gendered expectations, and both men and women profit from more equitable care [3, 20].
5.3. Methodological Considerations
This review was theory-guided with a preunderstanding that gendered norms exist in health care, which has influenced the selection of our search terms. Our directed literature search might be criticized as it potentially excluded studies that did not find/report gender differences. However, the aim of this study was not to prove if gendered norms in health care exist, which earlier research already has shown [2, 3, 13], but to collect and analyze gendered norms and gender bias as described in pain literature and deepen the knowledge about them. Our results support the idea that there is hegemonic masculinity and andronormativity in health care, and several patterns of gendered norms and consequences thereof could be explained by hegemonic masculinity and andronormativity. It might be important to underline that these theoretical concepts were not chosen in advance but found applicable after the categorization and analysis of the reviewed studies.
Another concern addresses the large number of included studies, providing a risk for fragmentation and selective interpretation of their content. This was balanced by the coding in three distinct and clearly defined theoretical categories, which provided a tight framework for the selection of relevant material [39, 42]. All authors discussed and agreed also on all categories. The descriptive basis of the substantive categories allowed to capture different patterns. There might be other patterns to be found in the reviewed studies. However, our findings were consistent throughout the reviewed studies and provided new insights, which should be further examined in both qualitative and quantitative studies.
A common dilemma in gender research involves how to create awareness about stereotypes without confirming or reinforcing them [40]. The purpose of this study was to challenge stereotypes about men and women, not to emphasize the differences. Gender norms are not the only norms that influence treatment decisions and patient-provider relations in health care. For instance, presumptions on age, race, and educational level have an impact on pain and intersect with each other and with gender [3, 97, 102], which is an important field for further elaboration.
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